Estandarización de las historias clínicas únicas y su incidencia en los servicios de atención médica en la red pública integral de salud en la ciudad de Guayaquil.

Abstract

The objective of this work was to evalúate the standardization of the clinical history and its impact on the quality of medical care of the Red Publica Integral de Salud in the city of Guayaquil through a qualitative methodology using descriptive, exploratory and documentary techniques executed through surveys aimed at internal and external users, as well as interviews with senior officials. Patient surveys showed dissatisfaction related to obtaining a shift for medical care and the delay for referral to a specialist who is handled manually with a physical form. The survey of doctors identified shortcomings in the treatments and diagnosis of the patient related to the mismanagement of the medical history that in several cases is done manually or is partially systematized. The interviews showed that each health system has isolated technological infrastructure without it being available to the medical staff working for another provider. This important fact led to the proposal to implement a Single Electronic Medical History for each citizen identified by their identity card, which includes the detailed and chronological information of each medical event regardless of the health provider they attend. This computing platform will enjoy portability and can be opened from any electronic device with internet connectivity from any geographical location where the doctor is taking advantage of the benefits of SaaS and Big Data and expanding the coverage of health systems.